CHAPTER 4: Assessment, Diagnosis, and Treatment Planning Substance Abuse and Addiction Treatment: Practical Application of Counseling Theory First Edition Todd F. Lewis Developed by Katie A. Wachtel, University of North Carolina at Greensboro

Lewis. Substance Abuse and Addiction Treatment: Practical Application of Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights Reserved 4-2 Introduction Thorough assessment for substance abuse is essential in fully understanding the impact substance abuse may be having on a client’s functioning Assessment should be an ongoing process Proper substance abuse assessment can help to determine possible substance related issues in clients who do not present primarily for substance abuse This chapter will discuss screening, assessment and diagnosis of substance abuse, as well as treatment planning considerations for substance abuse and addiction

Lewis. Substance Abuse and Addiction Treatment: Practical Application of Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights Reserved 4-3 Screening for Substance Use Problems Not the same as diagnosis or evaluation Refers to methods and procedures designed to rule out the possibility of substance use problems Can be formal (diagnostic interview) or informal (observational) Red flags: Physiological Psychological Behavioral

Lewis. Substance Abuse and Addiction Treatment: Practical Application of Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights Reserved 4-4 Screening Instruments and Tools Many of the existing instruments are in the public domain Choosing a screening tool can depend on validity, reliability, reading level, clinician familiarity, time commitment, and clinical utility/validity Examples CAGEAUI SASSI-3ASI DASTAUDIT MASTBiological screens

Lewis. Substance Abuse and Addiction Treatment: Practical Application of Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights Reserved 4-5 Assessment Assessment is conducted when the possibility of a substance problem is indicated through screening instruments Clinical interviews are perhaps the best way to gather information regarding substance use patterns Key components of the clinical interview: Referral source History of use Prior treatment history Current life functioning Family history or use Religious/Spiritual beliefs General personal history

Lewis. Substance Abuse and Addiction Treatment: Practical Application of Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights Reserved 4-6 Dimensions of Substance Addiction Interrelated but can operate independently Continuum from low risk to high risk 1. Use 2. Consequences 3. Physical adaptation 4. Behavioral dependence 5. Cognitive impairment 6. Medical harm 7. Motivation for change (Miller et al., 2011)

Lewis. Substance Abuse and Addiction Treatment: Practical Application of Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights Reserved 4-7 Assessment Protocol Example Gather information from a general diagnostic interview If the client shows signs of problematic substance use, administer screening instruments (CAGE, AUDIT, MAST, DAST etc.) If client appears to have moderate to severe substance use, administer assessment instruments (AUI, ASI, SASSI-3) Optional: personality inventories (MMPI-2, MCMI-III)

Lewis. Substance Abuse and Addiction Treatment: Practical Application of Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights Reserved 4-8 Providing Feedback Clients can become defensive about the results of their assessment, so it is important to provide feedback in a caring, nonthreatening manner Elicit-Provide-Elicit Elicit information about what the client wants to know Provide information and feedback about results Elicit client’s thoughts and feelings about the information (Rollnick, Mason, & Butler, 1999)

Lewis. Substance Abuse and Addiction Treatment: Practical Application of Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights Reserved 4-9 Substance-Related Diagnoses Diagnoses come from the DSM-IV-TR Separated into Substance Use Disorders (SUD) and Substance Induced Disorders (SID) SUDs Abuse Dependence SIDs Intoxication Withdrawal

Lewis. Substance Abuse and Addiction Treatment: Practical Application of Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights Reserved 4-10 Dual Diagnosis Refers to clients who have one or more Substance Related Disorders and at least one other diagnosis on Axis I or II A majority of clients who present for substance related issues also suffer from psychological concerns Mental health diagnoses and substance abuse often have a reciprocal relationship and it can be difficult to determine which came first Integrated treatment models are most effective for dual diagnoses

Lewis. Substance Abuse and Addiction Treatment: Practical Application of Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights Reserved 4-11 Changes in the DSM-V Renaming the Substance-Related Disorders chapter to Addiction and Related Disorders This section will include non-chemical addictions, such as gambling and Internet addictions Integration of abuse and dependence into a single construct Diagnoses will be given on a continuum of severity 2-3 criteria = mild 4-5 criteria = moderate 6+ criteria = severe 2 out of 11 criteria meets criteria for a diagnosis Addition of craving as a criteria for diagnosis Deletion of withdrawal as a criteria for diagnosis

Lewis. Substance Abuse and Addiction Treatment: Practical Application of Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights Reserved 4-12 Treatment Settings Always provide the least restrictive environment possible Options: Medical Detoxification and stabilization Dual-diagnosis hospital inpatient Therapeutic communities and residential programs Partial hospitalization and day treatment Temporary recovery or halfway homes Intensive outpatient Outpatient

Lewis. Substance Abuse and Addiction Treatment: Practical Application of Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights Reserved 4-13 The Treatment Plan Comprehensive treatment plans provide structure and direction for the counseling process Provides accountability between clients and clinicians Possible components: Type of plan Problem Indicators Goals (short and long term) Objectives Methods/techniques Frequency of services provided

Lewis. Substance Abuse and Addiction Treatment: Practical Application of Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights Reserved 4-14 DO A CLIENT MAP (Seligman & Reichenberg, 2007) Diagnosis Objectives Assessments Clinician characteristics Location Interventions Emphasis Number Timing Medication Adjunct services Prognosis